Patterns and Prognosis of Local Recurrence of Nasopharyngeal Carcinoma after Intensity-modulated Radiotherapy

Objective: To investigate the patterns of local failure and prognosis in patients with locally recurrent nasopharyngeal carcinoma (rNPC) after primary intensity-modulated radiotherapy (IMRT). Methods: The data of 298 patients with locally rNPC after IMRT were retrospectively analyzed. Magnetic resonance images of the initial and recurrent tumors were reviewed and, for patients with extra-nasopharyngeal local recurrence, the gross tumor volume of local recurrence was transferred to the original IMRT plan for dosimetry analysis. Significant prognostic factors for overall survival (OS) were selected by multivariate Cox regression analysis. Results: The commonest recurrence sites were the nasopharynx (93%, 277/298) and skull base (53.7%, 160/298). Of the 21 patients with extra-nasopharyngeal recurrence (19 cases valid), 12 had in-field failures, 4 had marginal failures, and 3 had out-field failures. The ethmoid sinus (57.1%, 4/7) and nasal cavity (28.6%, 2/7) were the most frequent sites of marginal and out-field failures. After median follow-up of 37 months, the 3-year and estimated 5-year OS rates were 57.3% and 41.7%, respectively. Multivariate analysis showed that age, recurrence interval, plasma Epstein-Barr virus (EBV) DNA level, and recurrent T stage were independent prognostic factors for OS. Conclusions: Local failure after IMRT occurs most commonly in the nasopharynx and skull base. In patients with extra-nasopharyngeal recurrence, in-field failure remains the main failure pattern, and marginal and out-field failures mainly occur in the ethmoid sinus and nasal cavity. Elder age, shorter recurrence interval, detectable plasma EBV DNA, and advanced recurrent T stage are negative predictors of OS in patients with rNPC.

Failure Patterns Within Different Histological Types in Sinonasal Malignancies: Making the Complex Simple

OBJECTIVE

To analyze the failure patterns in patients with different histological subtypes of sinonasal malignancies (SNMs).

STUDY DESIGN

Retrospectively gathered data.

SETTING

Academic university hospital.

METHODS

Patients with SNMs treated at a tertiary referral center between January 1999 and January 2019 were included. We assessed the failure patterns within different histological subtypes.

RESULTS

The study included 897 patients. The median follow-up time was 100 months. Adenoid cystic carcinoma (ACC) had a moderate risk of developing local recurrence (LR) and distant metastasis (DM). Compared with ACC, squamous cell carcinoma (SCC), adenocarcinoma (AC), soft tissue sarcoma (STS), and mucosal melanoma (MM) were classified as a high LR risk group. For DM, neuroendocrine carcinoma (NEC), STS, and MM were in the high-risk group.

CONCLUSIONS

ACC had intermediate local and distant failure risks, while SCC, AC, STS, and MM were at high LR risks. NEC, STS, and MM were at high DM risk.

Failure pattern and radiotherapy exploration in malignant pleural effusion non-small cell lung cancer treated with targeted therapy

Purpose

Actionable mutations are common in non-small cell lung cancer(NSCLC)with malignant pleural effusion(MPE)(MPE-NSCLC). The pattern of failure in MPE-NSCLC treated with targeted therapy after MPE control remains unclear. We aimed to investigate the failure pattern of such patients in a cohort study and explore the possibility of radiotherapy.

Patients and methods

Computed tomography scans of 86 patients were reviewed in this study. We classified first pattern of failure after MPE control as initial disease sites only (IF), new distant sites only (NF), or IF and NF detected simultaneously (INF). Patients evaluated suitable for radiotherapy after disease progression were divided into two groups: D group without radiotherapy and RD group with radiotherapy. The Kaplan-Meier method and log-rank test were used for survival analyses.

Results

Disease progression after MPE control was observed in 42 patients with complete serial imaging. Median time to any progression was 9.5 months. Rate of the IF, NF and INF were 50%, 17% and 33% for all patients,60%,0% and 40% for patients with MPE recurrence (n=10,23.8%) and 47%, 22% and 31% for patients (n=32,76.2%) without MPE recurrence, respectively. Out of 10 patients(23.8%) with MPE recurrence, 7 patients simultaneous underwent primary tumor progression and 5 MPE were cytologically confirmed in 7 patients with examination. The overall survival (OS )rates at 1, 2, 3 years for the RD group and D group were 88.2%, 50.5%, 21.7% and 80.0%, 20.3%, 0%, respectively; the corresponding MST were 26.1 months and 17.5 months, respectively (χ2 = 4.959, p =0.026).

Conclusions

Our data indicates that 50% of patients with actionable mutations MPE- NSCLC after MPE control are likely to fail at their initial sites of disease and the use of radiotherapy may bring OS benefits during the course of their disease. Multicenter RCT is necessary to confirm the result in the future.

Patterns and prognosis of regional recurrence in nasopharyngeal carcinoma after intensity-modulated radiotherapy

OBJECTIVE

We analyzed the patterns of lymph node (LN) failure and prognosis in patients with regional recurrent nasopharyngeal carcinoma (rNPC) alone after primary intensity-modulated radiotherapy (IMRT).

METHODS

A total of 175 patients who were treated with IMRT between 2010 and 2015 and who experienced regional recurrence alone were included. Recurrent LNs were re-located in the initial pretreatment imaging and IMRT plan and failures were classified as in-field or out-field based on target volume delineation. All patients underwent curative salvage treatment. Independent prognostic factors for overall survival (OS) were selected by multivariate Cox analysis.

RESULTS

Level IIb (49.1%, 86/175) was the most frequent recurrence site, followed by level IIa (36%), level III (18.9%), level IVa (12%), the retropharyngeal region (8%), level Va (6.9%), and the parotid region (6.9%). A total of 264 recurrent LNs were recorded: 149 (56.4%) were classified as in-field failure with a prescribed dose ≥66 Gy, 60 (22.7%) with 60 to <66 Gy, 32 (12.1%) with 50 to <60 Gy, and 23 (8.7%) as an out-field failure, which mainly occurred in the parotid region and level Ib. After a median follow-up of 52.8 months, the estimated 5-year OS rate was 66.9%. Multivariate analysis showed that age, plasma Epstein-Barr virus DNA level, extranodal extension, lower neck involvement, and parotid LN recurrence were independent prognostic factors of OS.

CONCLUSIONS

In-field failure represented the main pattern of regional recurrence and out-field failure mainly occurred in the parotid gland and level Ib. Patients with regional rNPC alone had a good prognosis after salvage treatment.

Experimental Investigation of Shale Tensile Failure under Thermally Conditioned Linear Fracturing Fluid (LFF) System and Reservoir Temperature Controlled Conditions

Linear fracturing fluid (LFF) provides viscosity driven benefits of proppant suspensibility and fluid loss control, and with the use of a breaker agent, flowback recovery can be greatly enhanced. Shale tensile strength is critical in the prediction of fracture initiation and propagation, but its behavior under the interaction with LFF at reservoir temperature conditions remains poorly understood. This necessitated an in-depth investigation into the tensile strengths of Eagle Ford and Wolfcamp shales under thermally conditioned LFF and reservoir temperature controlled conditions. Brazilian Indirect Tensile Strength (BITS) testing was carried out for the quantitative evaluation of shale tensile strength, followed by extensive failure pattern classifications and surface crack length analysis. The thermally conditioned LFF saturation of shale samples led to average tensile strength (ATS) increases ranging from 26.33–51.33% for Wolfcamp. Then, for the Eagle Ford samples, ATS increases of 3.94 and 6.79% and decreases of 3.13 and 15.35% were recorded. The exposure of the samples to the temperature condition of 90 °C resulted in ATS increases of 24.46 and 33.78% for Eagle Ford and Wolfcamp shales, respectively. Then, for samples exposed to 220 °C, ATS decreases of 6.11 and 5.32% were respectively recorded for Eagle Ford and Wolfcamp shales. The experimental results of this research will facilitate models’ development towards tensile strength predictions and failure pattern analysis and quantifications in the LFF driven hydraulic fracturing of shale gas reservoirs.

A Numerical Investigation into the Effect of Homogeneity on the Time-Dependent Behavior of Brittle Rock

To investigate the brittle creep failure process of rock material, the time-dependent properties of brittle rocks under the impact of homogeneity are analyzed by the numerical simulation method, RFPA-Creep (2D). Deformation is more palpable for more homogeneous rock material under the uniaxial creep loading condition. At a low stress level, diffusion creep may occur and transition to dislocation creep with increasing applied stress. The law for increasing creep strain with the homogeneity index under a constant confined condition is similar to the uniaxial case, and dislocation creep tends to happen with increasing confining pressure for the same homogeneity index. The dilatancy index reaches its maximum at a high stress level when rock approaches failure, and the evolution of the dilatancy index with the homogeneity index under the same confining pressure is similar to the uniaxial case and is more marked than that under the unconfined condition. Both uniaxial and triaxial creep failure originate from the ductile damage accumulation inside rock. The dominant shear-type failure is exhibited by uniaxial creep and the conventional compression case presents the splitting-based failure mode. Under confining pressure, the creep failure pattern is prone to shear, which is more notable for the rock with higher homogeneity.

Long-Term Results of Intensity-Modulated Radiotherapy for T4 Nasopharyngeal Carcinoma: New Insight into the Value of Concurrent Chemotherapy

The aim of the study was to report long-term results of intensity-modulated radiotherapy for patients with T4 classification nasopharyngeal carcinoma (NPC). From September 2007 to January 2013, 155 patients were retrospectively analyzed. The estimated 10-year local recurrent-free survival (LRFS), regional recurrent-free survival (RRFS), distant metastasis-free survival (DMFS), and overall survival (OS) rates were 79.4%, 93.2%, 69.0%, and 54.2%, respectively. Cycle number of chemotherapy was a significant predictor of LRFS, OS, and progression-free survival. There was no significant difference in survival rates between patients treated with induction chemotherapy (IC) plus concurrent chemoradiotherapy (CCRT) and patients with IC plus IMRT and adjuvant chemotherapy (AC).

Changes in the Fracture Toughness under Mode II Loading of Low Calcium Fly Ash (LCFA) Concrete Depending on Ages

This study investigated the influence of the curing time on the fracture toughness of concrete produced with different content of low calcium fly ash (LCFA). During the study, the amounts of 20% and 30% of pozzolanic additive were used. In order to observe the effect of the applied pozzolanic additive on the analyzed concrete properties, the obtained results were compared with the values obtained for the reference concrete. Compressive strength—f_cm and fracture toughness, by using mode II loading—K_IIc (shearing), were determined between the 3rd and 365th days of curing. In the course of experiments, changes in the development of cracks in individual series of concrete were also analyzed. In addition, the microstructures of all composites and the nature of macroscopic crack propagation in mature concretes were assessed. It was observed that the greatest increase in fracture toughness at shear was in the case of reference concrete during the first 28 days, whereas, in the case of concretes containing LCFA, in the period of time above 4 weeks. Furthermore, concrete without the LCFA additives were characterized by a brittle fracture. In contrast to it, concretes with LCFA additives are mainly characterized by a quasi-plastic process of failure. Moreover, most of the samples showed a typical pattern of the destruction that occurs as a result of shearing. The presented test results may be helpful in selecting the composition of concrete mixtures containing LCFA to be used in concrete and reinforced concrete structures subjected to shear loads.

Numerical Studies on Damage Behavior of Recycled Aggregate Concrete Based on a 3D Model

This paper develops a 3D base force element method (BFEM) based on the potential energy principle. According to the BFEM, the stiffness matrix and node displacement of any eight-node hexahedral element are derived as a uniform expression. Moreover, this expression is explicitly expressed without a Gaussian integral. A 3D random numerical model of recycled aggregate concrete (RAC) is established. The randomness of aggregate was obtained by using the Monte Carlo random method. The effects of the recycled aggregate substitution and adhered mortar percentage on the elastic modulus and compressive strength are explored under uniaxial compression loading. In addition, the failure pattern is also studied. The obtained data show that the 3D BFEM is an efficient method to explore the failure mechanism of heterogeneous materials. The 3D random RAC model is feasible for characterizing the mesostructure of RAC. Both the substitution of recycled aggregate and the percentage of adhering mortar have a non-negligible influence on the mechanical properties of RAC. As the weak points in the specimen, the old interfacial transition zone (ITZ) and adhered mortar are the major factors that lead to the weakened properties of RAC. The first crack always appears in these weak zones, and then, due to the increase and transfer of stress, approximately two-to-three continuous cracks are formed in the 45°direction of the specimen.

Effect of material thickness on the fracture resistance and failure pattern of 3D-printed composite crowns

AIM

To evaluate the fracture resistance and failure pattern of 3D-printed and milled composite resin crowns as a function of different material thicknesses.

MATERIALS AND METHODS

Three typodont tooth models were prepared to receive a full coverage composite resin crown with different thicknesses (0.5, 1.0, and 1.5 mm). The prepared master casts were digitally scanned using an intraoral scanner, and the STL files were used to fabricate 60 nanocomposite crowns divided into two groups according to the material thickness (n = 10) and fabrication method: a 3D-printed group (3D) using an SLA printer with nanocomposite, and a milled group (M) using a milling machine and composite blocks. All crowns were adhesively seated on stereolithography (SLA)-fabricated dies. All samples were subjected to thermomechanical loading and fracture testing. The load to fracture [N] was recorded and the failure pattern evaluated. Data were statistically analyzed using a two-way ANOVA followed by a Bonferroni post hoc test. The level of significance was set at α = 0.05.

RESULTS

The 3D group showed the highest values for fracture resistance compared with the milled group within the three tested thicknesses (P < 0.001). The 3D and M groups presented significantly higher load to fracture for the 1.5-mm thickness (2383.5 ± 188.58 N and 1284.7 ± 77.62 N, respectively) compared with the 1.0-mm thickness (1945.9 ± 65.32 N and 932.1 ± 41.29 N, respectively) and the 0.5-mm thickness, which showed the lowest values in both groups (1345.0 ± 101.15 N and 519.3 ± 32.96 N, respectively). A higher incidence of irreparable fractures was observed for the 1.5-mm thickness.

CONCLUSION

3D-printed composite resin crowns showed high fracture resistance at different material thicknesses and can be suggested as a viable solution in conservative dentistry.

Randomized phase II trial comparing tumor bed alone with tumor bed and elective nodal postoperative radiotherapy in patients with locoregionally advanced thoracic esophageal squamous cell carcinoma

This study compares the outcomes of different postoperative radiation fields for locoregionally advanced thoracic esophageal squamous cell carcinoma (ESCC) patients. This is a multi-institution randomized phase II trial and noninferior study. Patients with ESCC who had undergone esophagectomy (stage T3-4N0-3M0) were enrolled and randomized into the large-field irradiation arm (LFI; tumor bed and elective lymph node region) and small-field irradiation arm (SFI; tumor bed only). The primary endpoint was whether the disease-free survival (DFS) of SFI was not inferior to LFI. The secondary endpoint was to evaluate the rationality of the radiation target volume by analyzing failure patterns. One hundred twenty-one patients (64 patients for LFI and 57 patients for SFI, respectively) were eligible in this mid-time analysis. The 1- and 3-year DFS was 79.9%, 46.2% for LFI and 67.6%, 44.3% for SFI, respectively (P = 0.414). The locoregional recurrence-free survival (LRFS) of LFI was significantly better than that of SFI (P = 0.003). However, there were no significant differences in the distant metastasis-free survival and overall survival between the two arms (P = 0.332, P = 0.405, respectively). The failure patterns of the two arms were significantly different (P = 0.002). For pT3-4N0-3M0 ESCC patients, postoperative radiotherapy with SFI showed a similar survival outcome to LFI. However, the LRFS of patients with SFI was worse than that of patients with LFI.

Comparative Analysis of Static and Dynamic Mechanical Behavior for Dry and Saturated Cement Mortar

Deformational and breakage behaviors of concrete and cement mortar greatly influence various engineering structures, such as dams, river bridges, ports, tunnels, and offshore rig platforms. The mechanical and petrophysical properties are very sensitive to water content and are controlled by the liquid part in pore spaces to a large extent. The objective of this paper is to investigate the water saturation effect on the strength characteristics and deformability of cement mortar under two loading conditions, static and dynamic compression. A set of cement mortar samples was prepared and tested to study the mechanical behavior in dry and saturated states. The first part of the research incorporates the study of static mechanical properties for dry and brine-saturated cement mortar through uniaxial compressive strength tests (UCS). Second, drop-weight impact experiments were carried out to study the dynamic mechanical properties (impact resistance, deformation pattern, and fracture geometry) for dry and saturated cases. The comparative analysis revealed that water saturation caused substantial changes in compressive strength and other mechanical characteristics. Under static loading, water saturation caused a reduction in strength of 36%, and cement mortar tended to behave in a more ductile manner as compared to dry samples. On the contrary, under dynamic loading conditions, water saturation resulted in higher impact resistance and fracture toughness as compared to dry conditions. In addition, fractures could propagate to smaller depths as compared to dry case. The study will help resolve many civil, mining, and petroleum engineering problems where cement structures undergo static as well as dynamic compression, especially in a hydraulic environment where these structures interact with the water frequently. To the best of our knowledge, the effect of water saturation on the dynamic mechanical properties of cement mortar has not been well understood and reported in the literature.

Physical and Mechanical Properties of a Bulk Lightweight Concrete with Expanded Polystyrene (EPS) Beads and Soft Marine Clay

The variation of physical and mechanical properties of the lightweight bulk filling material with cement and expanded polystyrene (EPS) beads contents under different confining pressures is important to construction and geotechnical applications. In this study, a lightweight bulk filling material was firstly fabricated with Singapore marine clay, ordinary Portland cement and EPS. Then, the influences of EPS beads content, cement content, curing time and confining pressure on the mass density, stress-strain behavior and compressive strength of this lightweight bulk filling material were investigated by unconsolidated and undrained (UU) triaxial tests. In these tests, the mass ratios of EPS beads to dry clay (E/S) were 0%, 0.5%, 1%, 2%, and 4% and the mass ratios of cement to dry clay (C/S) were 10% and 15%. Thirdly, a series of UU triaxial tests were performed at a confining pressure of 0 kPa, 50 kPa, 100 kPa, and 150 kPa after three curing days, seven curing days, and 28 curing days. The results show that the mass density of this lightweight bulk filling material was mainly controlled by the E/S ratio. Its mass density decreased by 55.6% for the C/S ratio 10% and 54.9% for the C/S ratio 15% when the E/S ratio increased from 0% to 4% after three curing days. Shear failure more easily occurred in the specimens with higher cement content and lower confining pressure. The relationships between compressive strength and mass density or failure strain could be quantified by the power function. Increasing cement content and reducing EPS beads content will increase mass density and compressive strength of this lightweight bulk filling material. The compressive strength with curing time can be expressed by a logarithmic function with fitting correlation coefficient ranging from 0.83 to 0.97 for five confining pressures. These empirical formulae will be useful for the estimation of physical and mechanical properties of lightweight concretes in engineering application.

Origin of Locoregional Recurrences After Definitive Intensity-modulated Radiation Therapy (IMRT) for Laryngeal Cancer Determined Based on Follow-up PET/CT Imaging

Purpose: The aim of our study was to report on patterns of failure using detailed information from follow-up positron emission tomography-computed tomography (PET/CT) scans for patients with laryngeal squamous cell carcinoma (SCCA) treated with definitive radiation therapy using intensity-modulated radiation therapy (IMRT).

Methods: One hundred and sixty-eight patients with laryngeal SCCA treated with definitive IMRT using a simultaneous integrated boost were included. The point of recurrence origin on follow-up PET/CT was determined using two separate data-driven methods. The first method, the mathematical epicenter point of origin (PO_Epi), calculated the mathematical focal epicenter point for which the maximum distance to the surface of the surrounding volume was smaller than for any other point. The second method, maximum standardized uptake value point of origin (PO_Max), calculated the voxel with maximum standardized uptake value (SUV) uptake within the recurrence volume. The failure pattern was then determined by whether the point of recurrence origin fell within the low, intermediate, or high-risk target volumes in the original treatment planning CT.

Results: Thirty-five primary/nodal recurrences in 33 patients were included in the analysis. In the PO_Epi method, 94% (33/35) of all recurrences originated either within the high-risk gross tumor volume (GTV_High-risk) or within an average of 0.9 ± 1.3 mm from it. In the PO_Max method, 91% (32/35) of all recurrences originated either within the GTV_High-risk or within an average of 1.8 ± 1.7 mm from it. There were no recurrences outside the low-risk planning target volume (PTV_Low-risk) for the PO_Epi method but there was one for the PO_Max method, which was 19.8 mm away from the edge of the gross tumor volume receiving 70 Gy (GTV₇₀). Increasing distance between the two different origin points was strongly correlated with the size of the recurrence volume.

Conclusion: The majority of recurrences for laryngeal cancer patients treated with definitive IMRT originated from within the high-dose treatment region. This can have implications for reducing clinical target volumes while using a risk-adaptive treatment approach to both constrain dose to critical areas and further escalate the dose to the gross tumor to improve locoregional control rates.

Investigation of long-term survival outcomes and failure patterns of patients with nasopharyngeal carcinoma receiving intensity-modulated radiotherapy: a retrospective analysis

Intensity-modulated radiotherapy (IMRT) has replaced the conventional radiotherapy (2D-RT) and improved clinical efficacy in Nasopharyngeal Carcinoma (NPC) patients. In the present study, we retrospectively analyzed the clinical characteristics of patients with NPC treated with IMRT to assess the long-term survival outcomes and failure patterns. Of the 527 patients, One hundred and twenty-one patients experienced treatment failure, 86 patients developed distant metastases, and 12 patients developed a second primary tumor. The local and regional recurrence rates were 31.4% and 14.0%, respectively. The 5-year overall survival (OS), progression-free survival (PFS), local recurrence-free survival (LRFS), regional relapse-free survival (RRFS), and distant metastatic relapse-free survival (DMFS) rates were 80.9%, 75.6%, 91.7%, 96.2%, and 83.0%, respectively. The 5-year LRFS rates of Stage T1-4 patients were 100.0%, 93.1%, 92.0%, and 85.8%, respectively. The 5-year DMFS rates of Stage N0-3 patients were 95.0%, 86.1%, 79.5%, and 67.2%, respectively. Multivariate analysis showed age and T-stage were independent predictors of OS, T-stage was an independent predictor of LRFS, and age and N-stage were independent predictors of PFS and DMFS.

In summary, the improved treatment results with IMRT are primarily due to the achievement of a higher local tumor control rate and OS in NPC patients. However, distant metastasis was the most commonly observed failure pattern after treatment. These results provide deep insights about the value of IMRT in the treatment and prognosis of NPC patients.

Characteristics of elongated and ruptured anterior cruciate ligament grafts: An analysis of 21 consecutive revision cases

Background/objective

Anterior cruciate ligament (ACL) reconstructions often fail without graft rupture. The purpose of this study was to compare the characteristics of patients with elongated and ruptured bone-patellar tendon-bone (BTB) grafts that required revision surgery.

Methods

Twenty one patients who required revisions of a BTB-reconstructed ACL between 2010 and 2015 were enrolled in this study. All patients were evaluated for bone tunnel position using computed tomography. Tunnel angle was calculated with radiographs. Stability under anaesthesia, and meniscus and cartilage condition were evaluated during the revision surgery. Age at primary surgery, time between primary and revision surgery, activity level, original tunnel position of the graft, and meniscus and cartilage condition were compared between elongated and ruptured grafts.

Results

Age at primary surgery was not significantly different between the two groups (p = 0.528). Time between primary and revision surgery as well as activity level were also not significantly different between the two groups (p = 0.010 and p = 0.307, respectively). Femoral bone tunnel position was more proximal (p = 0.003), and radiographic tunnel angle was not significantly different between the two groups (p = 0.029). The rupture group was significantly more unstable on the pivot shift (p < 0.003). Meniscus degeneration, meniscus tear, and cartilage damage were not significantly different between the two groups (p = 0.030, p = 0.311, and p = 0.505, respectively).

Conclusion

The location of the original femoral tunnel was more proximal in patients with elongated grafts than in those with ruptured grafts. Different bone tunnel position from native ACL might lead to graft elongation.

Patterns of failure and clinical outcomes of definitive radiotherapy for cervical esophageal cancer

Purpose

Because of the scarcity of cervical esophageal cancer (CEC), data for this disease entity is limited. We aim to evaluate the outcomes, prognostic factors and failure patterns of CEC treated by contemporary radiotherapy (RT).

Methods

We retrospectively analyzed 86 CEC patients consecutively treated between 2007 and 2015 by definitive RT with or without concurrent chemotherapy. RT was mainly delivered with Intensity Modulated Irradiation Therapy (IMRT) or Volumetric-Modulated Arc Therapy (VMAT). Statistical analyses were performed on survival, prognostic factors and failure patterns.

Results

The median follow-up time was 19.4 months. The 3-year overall survival (OS), local regional failure free survival (LRFFS), distant metastatic free survival (DMFS), and progression free survival (PFS) were 53.6%, 57.9%, 81.5% and 41.5%, respectively. Independent predictors for poorer OS were N stage, hoarseness and recurrent laryngeal nerve lymph node (RLN) involvement, and predictors for LRFFS were N stage and EQD2 (equivalent dose in 2 Gy fraction) to gross tumor volume (GTV), with ≥ 66Gy achieving local control of 94.7%. Patients receiving elective nodal irradiation (ENI) had better nodal regional control than those receiving involved field irradiation (IFI). 31 (36%) patients had treatment failure and 15 (17.4%), 8 (9.3%) and 14 (16.2%) patients had local, regional, and distant failure, respectively. 86.7% (13/15) local failures were within GTV, and supraclavicular region (62.5%, 5/8) was the most common regional failure site. No severe toxicities were observed.

Conclusions

Our results seem to indicate that good locoregional control might be achieved for CEC with adequate radiation dose and treatment planning approaches.

Clinical results of definitive chemoradiotherapy for cervical esophageal cancer: Comparison of failure pattern and toxicities between intensity-modulated radiotherapy and 3-dimensional conformal radiotherapy

BACKGROUND

The efficacy of intensity-modulated radiotherapy (IMRT) for cervical esophageal cancer has not been determined.

METHODS

Eighty patients with cervical esophageal cancer treated with definitive chemoradiotherapy from 2002 to 2014 were analyzed. Overall survival (OS), failure patterns, and toxicity incidence were compared between the IMRT (N = 32) and 3D conformal radiotherapy (RT; N = 48) groups.

RESULTS

The median follow-up was 35.9 months. The 3-year OS of the IMRT, 3D conformal RT, and total groups was 81.6%, 57.2%, and 66.6%, respectively. Pulmonary toxicity was not observed with IMRT. Six of 62 cases (9.6%) with nodal involvement developed upper cervical node recurrence outside the prophylactic region. Ten patients in the IMRT group were salvaged, and 60% survived without recurrence; 20% of the 3D conformal RT group was salvaged.

CONCLUSION

The IMRT group was comparable with 3D conformal RT group, with a better salvage rate. We recommend extended cervical irradiation for nodal involvement.

Radiotherapy Alone or Concurrent Chemoradiation for Esophageal Squamous Cell Carcinoma in Elderly Patients

Purpose: The reported data of elderly ESCC are rather limited and there is a lack of information to guide treatment decisions for elderly patients with esophageal cancer. This study aims to identify the efficacy and factors for optimal treatment approaches for elderly esophageal squamous cell carcinoma (ESCC) treated with radiotherapy (RT) alone or concurrent chemoradiation (CCRT).

Methods: This study included 184 I-III elderly ESCC patients aged ≥70 years treated by oral single agent CCRT (sCCRT) or double agents CCRT (dCCRT) or RT alone at a single institution in China. RT was delivered with Intensity Modulated Irradiation Therapy (IMRT) or Volumetric-Modulated Arc Therapy (VMAT). Sequential or simultaneous integrated boost (SIB) approach was applied for GTV dose escalation. Toxicities were evaluated by criteria of Radiation Therapy Oncology Group. Statistical analyses were performed on survival and failure patterns.

Results: At a median follow-up time of 15.5 months, the 2- and 3-year estimated overall survival (OS) were 43.5% and 35.2%, respectively. T and N stage, GTV dose (cutoff value 56Gy), simultaneous integrated boost (SIB) technique and CCRT were significant predictors for the outcomes. sCCRT was significantly associated with higher OS, LRFS, and DFS when compared with RT alone and no difference was observed between sCCRT and dCCRT. 44% patients experienced treatment failure, among whom 65.4% developed local failure. 81.3% local failure occurred in GTV and 70.6% regional failures occurred out of radiation field. dCCRT was the only independent prediction factor for grade ≥ 2 neutropenia and gastrointestinal reactions compared with sCCRT and RT alone. No significant difference of toxicities was observed between sCCRT and RT alone.

Conclusions: Our results demonstrated that CCRT in elderly patients had significant survival benefit compared to RT alone, especially using Single oral agent. sCCRT had less toxicities compared to dCCRT, and the toxicity was similar to RT alone. GTV dose ≥ 56 Gy and SIB technique were optimal approaches for radiotherapy.

Chemoradiotherapy for extrahepatic bile duct cancer with gross residual disease after surgery

BACKGROUND

The purpose of the present study was to analyze the outcome of chemoradiotherapy for extrahepatic bile duct (EHBD) cancer patients with gross residual disease after surgical resection.

PATIENTS AND METHODS

We retrospectively analyzed 30 patients with EHBD adenocarcinoma who underwent chemoradiotherapy after palliative resection (R2 resection). Postoperative radiotherapy was delivered to the tumor bed including residual tumor and regional lymph nodes (range=40-55.8 Gy). Most patients underwent chemoradiotherapy concurrently with 5-fluorouracil (5-FU) or gemcitabine.

RESULTS

The 2-year locoregional progression-free, distant metastasis-free and overall survival rates were 33.3%, 42.4% and 44.5%, respectively. High radiation dose≥50 Gy had a marginally significant impact on superior locoregional progression-free survival compared to 40 Gy (p=0.081). One patient developed grade 3 late gastrointestinal toxicity.

CONCLUSION

Adjuvant chemoradiotherapy for EHBD cancer patients with gross residual disease after surgery was well-tolerated. There could be a chance for durable locoregional control and even long-term survival in selected patients.

Adjuvant cisplatin-based chemotherapy in nonsmall-cell lung cancer: new insights into the effect on failure type via a multistate approach

BACKGROUND

Adjuvant cisplatin-based chemotherapy has become the standard therapy against resected nonsmall-cell lung cancer (NSCLC). Because of variable results on its late effect, we reanalyze the long-term data of the International Adjuvant Lung Cancer Trial (IALT) to describe in details the role of adjuvant chemotherapy.

PATIENTS AND METHODS

In the IALT, 1867 patients were randomized between adjuvant cisplatin-based chemotherapy and control, who were followed up for a median of 7.5 years. Of these, 1687 patients were enrolled from 132 centers accepting to report the times to cancer events. We used event history methodology to estimate the effects of adjuvant chemotherapy on the risks of local relapse, distant metastasis, and death.

RESULTS

Adjuvant chemotherapy was highly effective against local relapses [HR = 0.73; 95% confidence interval (CI) 0.60-0.90; P = 0.003] and nonbrain metastases (HR = 0.79; 95% CI 0.66-0.94; P = 0.008) but not against brain metastases (HR = 1.1; 95% CI 0.82-1.4; P = 0.61). The effect on noncancer mortality was nonsignificant during the first 5 years (HR = 1.1; 95% CI 0.81-1.5; P = 0.29), whereas the risk of noncancer mortality was subsequently higher with treatment (HR = 3.6; 95% CI 2.2-5.9; P < 0.001). This harmful effect, however, potentially concerned only about 2% of the patients at 8 years.

CONCLUSION

Adjuvant cisplatin-based chemotherapy reduced the risk of local relapse and of nonbrain metastasis, thereby improving survival. This treatment exerted no residual effect on mortality during the first 5 years, but a higher risk of noncancer mortality was found thereafter. Detailed long-term follow-up is strongly recommended for all patients in randomized trials evaluating adjuvant treatments in NSCLC.